Care Plan

CareplaninformationAdobeScanJun22022.pdf

RIGHT KNEE ARTHROTOMY .

Pt states did well after bilateral TKAs in 2014 but feel on R knee 2-3 months ago and h as h ad P';'fellar pain since that ~ime , especially with ...:,eight-bearing , flexion , turning . Saw Dr . F risch with concern for loosening of prosthesis . No recent or other UTI/URI sx ch est pain , sh ortness of breath, orthopne_a , PND, dizziness , syncope , palpitations , LE pain/s...:,elling , fevers/chills , he'.3daches, confus~on , numbness/tingling/weakness , speech/swallowing/vision changes , back pain, abdominal pain, nausea, vomiting, diarrhea, constipation , melena/hematochezia , or COVID symptoms . "

Onset (date of injury,illness, surgery): 5/27/22

General Observations: Patient lying supine in bed with CoolJet ice pack on R knee and RN present in room providing pain meds.

Precautions: Fall risk

Pain Scale:1,/10 Location: R knee

Prior Level of Function (PLOF): Patient was independent with ADLs/lADLs at baseline.

Previous Living Environment: Lives in an apartment building with elevator

Equipment Owned/At Home: Rollator, SPC

SUBJECTIVE: "I've been through this before"

OBJECTIVE:

COGNITION: Orientation: A&Ox3 Follows Commands: able to follow 2-3 step commands Attention: intact

~:,~~rx~;~:~tess: demonstrates good FWW awareness, pacing self during tasks

VISUAL/PERCEPTION: Acuity: read time on clock: intact Other: NIA

HAND DOMINANCE: right

SENSATION: . · ht T h· intact Right (R) upper extre~1ty (UE)_ Lrg ouh~ i~tact Left (L) upper extremity (UE) Light Touc .

COORDINATION: Gross motor: . Right hand finger to nose_: intact Left hand finger to nose: intact

Fine Motor: . · t ct Right hand opposition tip to tip: ,n a L

~ :::::::-----_ -='---·-- \an of cafe.

_P 3-5 days/wk I n of care . · goals/pa heraPY _

T R

E A

T M

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V ID

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IS S

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H O

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TREATMENT PROVIDED THIS S . . . and completed . · ESSION : Order received chart reviewed evaluation initiated

Bed mobility , t ransfers , gait training and CPM set up

HO~E EXE~ CISE PROGRAM(Specify exercise): LE strengthening Pat1ent/Fam1ly verbalized/demonstrated good understanding.

EDUCATION/DISCHARGE INSTRUCTION: Therapist provided education on the following topics : energy conservation , goals , positioning, role of PT, treatment plan and role of PT.

Follow ORTHO Protocol (Ortho patient ONLY. YES/NO): yes

ASSESSMENT: Patient seen after R knee Arthrotomy who presents with decreased ambulation tolerance, pain in R knee, decreased R knee ROM and strength of LE, decreased dynamic and static balance without device. Patient at increased risk for falls related to impairments. Pt to benefit from skilled services to improve balance, strength, ROM, gait to return to PLOF

Stroke Modified Rankin Scale: GCS NA

Recommendations : Initiate/continue PT services

Equipment Needed Upon Discharge: Rolling walker

Interventions: Transfer Training , Gait Training, Balance Activities , Therapeutic Exercises and Neuromuscular Re-Education

Discharge Destination : Home

TREATMENT FREQUENCY: 5xs a week

PREDICTED DURATION OF THERAPY: 1 week

SAFETY EDUCATION: Therapist assisted patient with set up of CPM at 70 degs as per Rn request. Therapist waited for patient to go through two full cycles before leaving. Patient expressed no discomfort however requested place of icepack on R knee for pain management. Therapist left patient with DVT cuff on LLE, CPM on R LE at 70 deg with ice pack on there. All needs met with call light in reach; educated to call RN if requiring assistance. Patient with good understanding of how to stop machine

.. .. •o .. ""' dw;:,a15 ,a;:,.l\. 11c cu ro oe compared before th .. ,< ct · •. pass. e next me 1cat10n

. '

O_BJECTIVE: . _ . J..Jl 7 H1Story of Present Illness: Patient 1s a 62 yo female wOh hx of bilateral TKAs 1n 2014, fell on R

_ knee 2-3 months ago and has had patellar pain since then during WB , flexion and turning . "' Patient with procedure 5/27 for R kne Arthrotomy. ·

Date of Onset: 5/27-surgical date

PT Diagnosis: Decreased functional mobility.

Precautions/Weight-Bearing Status: WBAT

General Observations: Patient supine in bed with bilateral DVT cuffs and ice pack on R knee

VITALS: supine: BP: 149/77 mmHg HR: 62 bpm SpO2: 98%

COGNITION

Status

Orientation oriented x 3

Ability to Follow follows Commands commands

Attention Intact

Memory Intact

Safety Intact Awareness

LOWER EXTREMITY RIGHT LEFT

LOWER LOWER EXTREMITY EXTREMITY Limited knee WFL Range of

flexion to 70 deg Motion passively Limited 4/5 Manual Muscle

assessment due Testing to pain

OTHER STRENGTH/ ROM: Patient limited assessment of RLE due to pain and swelling COORDINATION

No Deficits

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Left hand opposition tip to tip : intact

MUSCLE TONE: ,,,.-- Right Upper Extremity (UE) : WNL 7

Left Upper Extremity (UE) : Decreased muscle tone d/t previous CVA

ACTIVE RANGE OF MOTION: /"- Right Upper Extremity: WNL

4117'3 Left Upper Extremity: WNL -- GROSS MUSCLE STRENGTH:

/ Right Upper Extremity : Grossly 4+/5 Left Upper Extremity : Grossly 3+/5, residual CVA symptoms

BALANCE: Static Sitting : good Dynamic Sitting : good Static Standing : fair plus Dynamic Standing : fair

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BED MOBILITY: / Supine to Sit: supervisoin

Sit to Stand : close supervision

Bed to Chair: did not assess this date

SELF-CARE: Eating/Feeding : independent Grooming : set up assist for standing at sink tasks including wash ing face Upper Body (UB) Dressing : NT, deferred this date Lower Body (LB) Dressing : set up assist with AE including sock aid for doning/doffing socks Bathing : NT Toileting : NT Toilet Transfer: NT Shower/Tub Transfer: N/A at this time Homemaking : NIA at this time

ASSESSMENT:

Patient's response to occupational therapy interventions : good . Patient with prev ious B TKA and residual CVA L sided weakness . She requires increased time to complete tasks , however, was able to demonstrate bed mobility and functional transfers with close supervision . Patient familiar with AE including sock aid and reacher, re-educated on use of AE . Patient able to tolerate long functional mobility in hallway; educated on pacing strategies and energy conservation techniques to improve activity tolerance . Discussed DME as patient currently does not have shower chair at home . She would greatly benefit from a tub transfer be nch to improve safety with showering d/t balance deficits . O.T. encouraged AOL engageme nt and safe performance .

THERAPY PROBLEM LIST : Patient presents with decreased activity tolerance, res idual L sided weakness from prev ious CVA, balance defi cits wh ich li mit the pati ent's safety and independence wit hin AOL and functional mobility/transfers .

THERAPY STRENGTHS : coope rative , pleasant, motivated ,..A t

GOALS:

PATIENT/FAMILY THERAPY GOALS: To go home

SHORT-TERM GOALS (STG) (1-3 treatment visits) Patient will perform: 1. Increase standing tolerance to 1 O+ minutes with reports of minimal pain to improve activity tolerance 2. Demo sock aid with no verbal cues to increase independence with LB dressing 3. Retrieve 3 AOL items in room using Fl.NIN with close supervision

Occupational Therapy Plan of Care

Reason for Referral : impaired AOL skills, UE weakness, impaired balance , and pain

Recommendations : Will continue to see patient for skilled OT services while in house

Interventions: therapeutic exercise , self care/AOL training, balance activities , energy conservation, home exercise program, and family/caregiver training

Planned Frequency & Duration of Treatment: 3-5 days/wk

Additional Services: physical therapy evaluation

Discharge Destination: home with assist and home with OT